Readmissions, Sepsis and Accountability

By Dr. April Anderson, MD, chief medical officer, Premier Physician Network

In the not-so-distant past, sepsis-related mortality seemed like an elusive problem to tackle. Sure, some patients present with obvious signs and symptoms of infection and end-organ dysfunction, betraying their distress and laying bare their need for quick intervention. But others have more subtle and quieter declines, leading to a lag time before their diagnosis, which can be dangerous and detrimental.

Clinical decision tools and biomarkers have helped to unmask which patients are at risk for this decline and order sets have streamlined care, such that sepsis mortality has become top of mind, even in difficult to diagnose scenarios. Clinical teams have adopted these tools and are accustomed to the accountability of assuring that no stone is left unturned in the search for a dangerous and sneaky threat. Now that readmissions have been identified as a source of untoward outcomes for patients and frustration for caregivers, the same type of attention to detail and vigilance can be applied to this scenario.

On the day of discharge, calculators are available to predict which patients are the highest risk of experiencing a readmission. Hospital-based teams have lists of action items in place to assure that patients who are high-risk are set up for success when they are sent back to the community. These include assuring that patients understand their discharge plan, have what they need at home, and have a follow-up appointment with their provider in a timely manner.

Once the patient is back in their home, care managers are available to check in, and home care can be in the home within 48 hours. An essential element of the discharge plan for high-risk patients is assuring the timely follow-up appointment takes place, ideally with the individual’s primary care provider. This is the chance to clarify questions about lab tests, imaging studies and medications that were ordered or modified during the hospitalization.

Unlike sepsis, this complex care is not bundled into a single order set, and a crack in the system cannot be unmasked by a rising biomarker. But like sepsis, accountability and vigilance at each step can shore up our processes. In the same way that we would be very worried about an elderly patient with “confusion” who might be silently suffering from encephalopathy due to sepsis, we must now turn our full attention towards the small details that make a readmission more likely, such as not understanding discharge instructions, or having medications “all mixed up”.  This attention to detail on the part of each and every caregiver speaks to our mission of service to our patients and supports our values of integrity and excellence.

Back to the August 2026 Premier Pulse